Hawaii Revised Statutes Division 2. Business § 431:10A-208

(1) Specify the name and last known mailing address, if any, of the plan member and the name and mailing address of each recipient child covered by the order;

(2) Include a reasonable description of the type of coverage to be provided to the recipient child, or the manner in which the type of coverage is to be determined;

(3) State the period during which it applies;

(4) Specify the plan to which it applies; and

(5) Not require a plan to provide any type or form of benefit or option that the plan does not otherwise provide.